of it. Gillian managed to complete the final module but with a very low pass mark that left her feeling unhappy as she had worked hard. If what she had been drafting was not ‘good enough’, she wondered why the tutors had not talked it through with her more. She was left with a feeling of a lack of support from the tutor and teaching team, and she told them this in the evaluation at the end of the module. The module tutor was taken aback by her comments, because he had not known that Gillian was dyslexic.
Activity
Thinking about the complexity of the learning environment:
r How do you interpret what has happened in this scenario?
r What could Gillian have done to help herself as a learner?
r What could the academic team have done to help Gillian as a learner?
Reflection point As a learner:
r Do you have any particular learning needs? For example, due to a con- dition such as dyslexia, or a hearing or visual impairment.
r Have you advised the teaching team (e.g. academic tutor, placement supervisor) about your learning needs? If not, why do you think that might be, and what would help you to tell them?
r What would be the most useful things for the teaching team to know about your needs?
r Can you propose an action plan that ensures you are enabled to meet your full potential?
Conversely, the clinical environment confronts the learner with a range of social relations and a practice milieu out of which learning opportunities have to be sifted. Learning cannot be acquired in neat, pre-packaged units and emerge from the unpredictability of the day’s work, irrespective of the student’s level of study.
Practice settings can be overwhelmingly busy and pressured, so that all the novice sees is a whirr of activity as colleagues move from one task to the next, without taking breath. At the other end of the spectrum a student might be left wondering what they should do, or even what it is they are doing, when each community visit only lasts ten minutes, and after the dressing has been changed there is only a bit of chat with the patient. However, it is useful to consider the same community experience from the perspective of this older person who is now confined to the sitting room of his home, as described in the next patient’s perspective.
Patient perspective
‘Well she doesn’t stay for long, only seems like five minutes. Still, even though it’s the pressure sores, and not very nice, the five minutes does make a difference.
Sometimes I can be in a lot of pain, so it’s reassuring when she comes. Can’t talk about medical things to the carers or the meals-on-wheels man, can I? Not their business. Feel safer when she’s been, she’s made notes and reports back to the surgery, so I know I’ll be all right.’
Although fluid and complex, the practice setting is not a ‘free-for-all’ learning experience. It is important for the mentor to exercise some control within the placement on behalf of the learner, identifying learning opportunities that enable students to demonstrate their competence in certain activities or practices. Equally, learning opportunities that can support students to meet more personalized goals (e.g. enhancing time management or organizational skills) should be negotiated.
The balance between the requirements of the programme and the student’s own learning needs is likely to be managed through a form of learning agreement (Barrington and Street 2008).
Generally, learning opportunities are likely to range from the formal through to the incidental. Unplanned, incidental experiences can be a source of rich learning when they are examined through a set of reflective questions (e.g. see Fish et al.
1991; Johns 1999; Beckett and Hager 2002).
Reflection point
Consider the learning opportunities below and decide how they might be located on a learning continuum of formal−informal−incidental. Make a note of your thoughts.
Learning opportunities
r Shadowing a drugs round
r Undertaking a patient observation
r Writing case notes r Handover
r Accompanying a patient to theatre
r Working in the sluice room with a colleague r Taking a personal history
r Joining a ward round
r Enabling a patient to maintain their dignity when using a commode on the ward
r Observing a consultant discuss a diagnosis with a patient r Sitting with a bereaved family
r A supervision session
Any of the opportunities noted above could be understood as a formal experience.
However, a number of them might arise, unplanned, during the course of a day’s work. Payne and Scott (1982) devised a simple model for supervision in practice that can be adapted to frame our thinking about identifying and managing learning opportunities. Aspects of the model they describe are similar to the findings in more recent research into clinical supervision undertaken by Laitinen-Vaananen et al. (2007).
The formal/planned quadrant shown in Figure 8.2 represents the type of learning with which we are probably most familiar, where the learner and mentor agree a learning activity, such as accompanying a patient to the operating theatre. Ideally the learner and mentor will identify the student’s pre-existing knowledge, perhaps documenting this in a reflective journal or mentor note. As a learning team they will identify what other knowledge the student requires before undertaking the task− this might involve further reading, talking to other patients or shadowing the
FORMAL
• Professional conversation develops
• Planned activities
• Objectives agreed in advance
• Agreed methods for reaching objectives
• Direct supervision may occur in situ
• Reflective supervision/debrief held after the activity/event
• Activity agreed and undertaken on the spot.
• Direct supervision may occur in situ, or practices may be
demonstrated/modelled
• Reflective supervision/debrief held after the activity/event
PLANNED AD HOC
• Routine activity: bathing; escort to the pharmacy; community visit; staff lunch
• Conversational ‘small-talk’
• Activity arises out of the demands of the practice situation, or everyday routine
• Discussion arises out of the situation as it unfolds; although direct supervision may not be evident modelling may be more apparent
• Reflective supervision/debrief may or may not arise out of the activity/event
INFORMAL
Figure 8.2 A framework for clinical supervision (adapted from Payne and Scott 1982)
preoperative team in preparation. The mentor may directly supervise the student’s practice by talking the student through the activity as it occurs. This type of learn- ing opportunity might also be managed as an observation of the student’s practice (with no guiding talk from the mentor, unless practice is unsafe). On completion the mentor and student will evaluate the success of the undertaking, with a view to identifying further practice development.
In all quadrants of the model the way the mentor works has the potential to demonstrate good practice for the learner. Such demonstration, or modelling, may be the most powerful mode of communication in the practice learning setting.
It is likely to include the non-verbal presentation of the practitioner to a client – preferably calm, in positive control, attentive and concerned for the individual;
hopefully, not too harassed, or in a hurry. Modelling will also encompass verbal communication−tone and pitch of voice, speed of speech and quality of con- tent. The type of language used will demonstrate respect for the patient. These observations will inform the learner’s view of professional practice and acceptable behaviour. Sometimes we are harassed or not performing as we should. Irrespective of whether practices within an event can be described as ‘good’, ‘poor’ or ‘bad’ it is valuable to re-examine the experience.
Reflection point
Think about a recent practice learning experience where you worked alongside a senior colleague.
r What sort of behaviours did your colleague demonstrate and from your observations what did you learn about effective communication? For example, to remain focused on the patient, to carefully repeat key in- formation, to use touch to calm distress.
r Was there anything from this observation, or similar occasions, that seemed less than helpful in the interaction with the patient?
r Given these initial reflections, how might you continue to build your own communication skills through learning from your observations of others?
We tend to be less familiar with the informal/ad hoc learning opportunities that arise in practice. They can range from the dramatic, such as the sudden deterioration of a patient’s health, to the seemingly mundane – for example, stopping to have a brief chat on the way to the linen cupboard. Some sort of debrief is likely to arise out of a patient’s deterioration, possibly ongoing, as the team decide on interventions, or at a later stage when the team reflect back on what happened. It is important for learners to engage in these team debriefings, often located in this informal/ad hoc quadrant, as learning cannot be reliant on a mentor or one or two experts.
It is the ‘small’ unplanned encounters with patients and families that may go un- noticed and that are rarely the subject of our scrutiny. When service users choose to speak to us, and if we are receptive, then we can best meet their needs and learn something about how they cope with their circumstances. Listening to and under- standing the patient and their family and carers is crucial. To heal, survive or die
a good death individuals need their personhood to be respected and their psycho- logical wellbeing to be upheld. If we overlook the communications of patients we potentially undermine the efficacy of all our clever scientific interventions. Con- sider, for example, the implications of the patient’s experience in the next patient perspective.
Patient perspective
‘. . .half-hourly observations, apparently, so they came and took my blood pres-
sure, temperature and watched the machine every 20 minutes or so – sometimes more often if they were called away in the middle, or the machine started beep- ing. Never knew what that meant, but it was worrying. Never knew what any of it meant really, they didn’t talk to me about how I was doing, just kept taking the measurements. Always felt I was taking up their time when I asked questions so in the end just decided to keep quiet, expect they’d have let me know if anything was seriously wrong. . .’